PATIENT HISTORY TAKING TEMPLATE

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🏥 PATIENT HISTORY TAKING TEMPLATE

(✅ Tick all that apply. ⬜ Leave blank if not applicable.)

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👤 IDENTIFICATION DATA

Name	_______________________
Age	______ yrs
Sex	⬜ Male ⬜ Female ⬜ Other
Marital Status	⬜ Single ⬜ Married ⬜ Widow ⬜ Divorced
Address	_______________________
Occupation	_______________________
Date of Admission	________________
Date of Examination	________________
IP/OP No.	________________
Informant	⬜ Patient ⬜ Relative ⬜ Friend ⬜ Attendant ⬜ Other: ___________
Reliability of Informant	⬜ Good ⬜ Fair ⬜ Poor

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🗣️ CHIEF COMPLAINT(S)

Symptom	Duration	Tick if present
⬜ Fever	____ days/weeks	⬜
⬜ Cough	____ days/weeks	⬜
⬜ Breathlessness	____ days/weeks	⬜
⬜ Chest Pain	____ days/weeks	⬜
⬜ Abdominal Pain	____ days/weeks	⬜
⬜ Vomiting	____ days/weeks	⬜
⬜ Headache	____ days/weeks	⬜
⬜ Weakness	____ days/weeks	⬜
⬜ Back Pain	____ days/weeks	⬜
⬜ Swelling	Site: ____________	⬜
⬜ Others (Specify)	__________________	⬜

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📜 HISTORY OF PRESENTING ILLNESS

• ⬜ Onset: ⬜ Sudden ⬜ Gradual
• ⬜ Duration: ____________
• ⬜ Progression: ⬜ Increasing ⬜ Decreasing ⬜ Static
• ⬜ Associated symptoms:
  ⬜ Nausea ⬜ Diarrhoea ⬜ Loss of appetite ⬜ Weight loss ⬜ Sweating
  ⬜ Radiation of pain: ______________
  ⬜ Aggravating Factors: ____________
  ⬜ Relieving Factors: ____________
• ⬜ Treatment taken: ⬜ Yes ⬜ No
  If yes, specify: ________________________
• ⬜ Similar complaints in the past: ⬜ Yes ⬜ No

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🕰️ PAST MEDICAL HISTORY

Condition	Present	Duration	Treatment
⬜ Hypertension	⬜	______	__________
⬜ Diabetes Mellitus	⬜	______	__________
⬜ Tuberculosis	⬜	______	__________
⬜ Asthma/COPD	⬜	______	__________
⬜ Seizures	⬜	______	__________
⬜ Jaundice	⬜	______	__________
⬜ Surgery (Specify): ________	⬜	______	__________
⬜ Hospitalizations	⬜	______	__________
⬜ Others: _____________	⬜	______	__________

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🧬 FAMILY HISTORY

Disease	Present	Relationship
⬜ Hypertension	⬜	__________
⬜ Diabetes Mellitus	⬜	__________
⬜ Heart Disease	⬜	__________
⬜ Stroke	⬜	__________
⬜ Cancer	⬜	__________
⬜ Genetic Disorders	⬜	__________
⬜ TB	⬜	__________
⬜ Others: _______________	⬜	__________

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🧠 PERSONAL HISTORY

Item	Details
Diet	⬜ Veg ⬜ Non-Veg ⬜ Mixed
Appetite	⬜ Normal ⬜ Reduced ⬜ Increased
Bowel Habits	⬜ Normal ⬜ Constipation ⬜ Diarrhea
Bladder Habits	⬜ Normal ⬜ Frequency ⬜ Dysuria
Sleep	⬜ Normal ⬜ Disturbed ⬜ Insomnia
Addiction	⬜ Smoking ⬜ Alcohol ⬜ Tobacco ⬜ Drug abuse
Sexual History	⬜ Normal ⬜ Issues (Specify): __________
Occupation-related Exposure	⬜ Yes ⬜ No (If yes, specify): _________

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♀️ OBSTETRIC & GYNAECOLOGICAL HISTORY (If applicable)

Parameter	Details
Menarche Age	______ yrs
Cycle	⬜ Regular ⬜ Irregular
LMP	__________
Contraception	⬜ Yes ⬜ No (Type: ________)
Gravida	G:___ P:___ L:___ A:___
Obstetric Complications	⬜ Yes ⬜ No
Menopause	⬜ Pre ⬜ Post (Age: ____ yrs)

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💉 IMMUNIZATION HISTORY (if child or relevant)

Vaccine	Received	Age
⬜ BCG	⬜	___
⬜ OPV/DPT	⬜	___
⬜ MMR	⬜	___
⬜ Hepatitis B	⬜	___
⬜ COVID-19	⬜	___
⬜ Others: ____________	⬜	___

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⚠️ DRUG HISTORY

Drug Name	Indication	Duration	Side Effects
__________	__________	______	____________
⬜ Known Drug Allergies: __________________

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🏠 SOCIOECONOMIC HISTORY

Parameter	Detail
Socioeconomic status	⬜ Low ⬜ Middle ⬜ High
Living conditions	⬜ Pucca ⬜ Kutcha ⬜ Crowded
Water source	⬜ Tap ⬜ Borewell ⬜ Open
Toilet facility	⬜ Present ⬜ Absent
Education	⬜ Illiterate ⬜ School ⬜ Graduate
Monthly Income	₹ __________

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🧍‍♂️ GENERAL PHYSICAL EXAMINATION

Parameter	Value	Abnormalities
Built	⬜ Normal ⬜ Thin ⬜ Obese
Nourishment	⬜ Adequate ⬜ Inadequate
Pallor	⬜ Yes ⬜ No
Icterus	⬜ Yes ⬜ No
Cyanosis	⬜ Yes ⬜ No
Clubbing	⬜ Yes ⬜ No
Lymphadenopathy	⬜ Yes ⬜ No
Edema	⬜ Yes ⬜ No
Height	______ cm
Weight	______ kg
BMI	______ kg/m²

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🔍 VITAL SIGNS

Vital	Value
Temperature	______ °C
Pulse	______ /min, ⬜ Regular ⬜ Irregular
Respiratory Rate	______ /min
BP	______ mmHg
SpO₂	______ % on ⬜ Room air ⬜ Oxygen
RBS	______ mg/dL

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🔎 SYSTEMIC EXAMINATION

1. CVS (Cardiovascular System)

Finding	Present
⬜ Apex beat visible/palpable	⬜
⬜ Thrill	⬜
⬜ S1/S2 Normal	⬜
⬜ Murmur (Specify)	⬜

2. RS (Respiratory System)

Finding	Present
⬜ Trachea central/deviated	⬜
⬜ Breath sounds: ⬜ Vesicular ⬜ Bronchial
⬜ Added sounds: ⬜ Crepitations ⬜ Rhonchi

3. GI (Abdominal)

Finding	Present
⬜ Shape: ⬜ Flat ⬜ Distended
⬜ Tenderness	⬜
⬜ Guarding/Rigidity	⬜
⬜ Organomegaly: ⬜ Liver ⬜ Spleen
⬜ Bowel sounds present	⬜

4. CNS (Central Nervous System)

Finding	Status
Higher functions	⬜ Normal ⬜ Abnormal
Cranial Nerves	⬜ Normal ⬜ Abnormal
Motor	⬜ Normal ⬜ Weakness
Sensory	⬜ Intact ⬜ Loss
Reflexes	⬜ Normal ⬜ Exaggerated
Gait	⬜ Normal ⬜ Ataxic ⬜ Hemiplegic

5. Musculoskeletal

Finding	Present
⬜ Joint swelling	⬜
⬜ Tenderness	⬜
⬜ Deformities	⬜
⬜ Range of motion	⬜ Full ⬜ Restricted

6. Skin

Finding	Present
⬜ Rash	⬜
⬜ Ulcers	⬜
⬜ Pigmentation	⬜
⬜ Itching	⬜

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🧪 PROVISIONAL DIAGNOSIS

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📋 DIFFERENTIAL DIAGNOSIS

Dx	Features Supporting	Features Against
1.
2.

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📌 PLAN OF MANAGEMENT

Aspect	Plan
Investigations	__________________________
Initial Management	__________________________
Medications	__________________________
Referral (if any)	__________________________

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